RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02140
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Combat Engineer, medically separated from the Temporary Disability Retired List (TDRL) for “chronic diskogenic low back pain” with a disability rating of 10%.   

CI CONTENTION:  “Severe peripheral neuropathy.  Unable to lift, unable to work due to severe back and leg pain.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20061025	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Diskogenic LBP	5241	10%	There was no VA Examination Proximate to Separation in Evidence 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Diskogenic Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent L4-5 fusion on 12 February 2004.  He was placed on the TDRL on 20 November 2004.  

The May 2006 TDRL NARSUM (5 months prior to TDRL removal) indicated the CI ‘s back pain was “slight and occasional” and stated the CI’s overall condition was stable, but deferred to the pending orthopedic addendum (see below).  Civilian occupational functioning was not addressed by either examiner.  A post-surgical MRI demonstrated post-operative changes with normal alignment and no significant disc bulging.

At the 4 August 2006 orthopedic TDRL addendum, 4 months prior to separation, the CI complained of 6/10 LBP “better since surgery,” but still prohibited running and heavy lifting.  The physical examination recorded a normal gait and spinal contour with no spasm.  Measured thoracolumbar range of motion (ROM) was flexion of 70 degrees (normal 90) and combined ROM of 190 degrees (normal 240).  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5241 (spinal fusion), citing the findings and ROM evidence from the orthopedic addendum.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported on the TDRL orthopedic evaluation proximate to TDRL removal.  There was no abnormal gait or spinal contour that would justify the next higher 20% rating.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.   

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.    Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180015052, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       

Enclosure